Diverticular disease affects a large percentage of the US population, affecting over 30% among those older than 45 years old. It is responsible for ?300,000 hospitalizations per year in the United States and can lead to serious complications such as hemorrhage, obstruction, abscess, fistulae, or bowel perforation. 2 It is an extremely common reason for emergency room and outpatient visits and evaluations by general and colorectal surgeons. In the US, patients usually present with sigmoid diverticulitis in the setting of a normal immune system so surgeons will follow well-established practice guidelines for treatment. However, there may be special circumstances in which the management of diverticulitis is not as straightforward. In this article, we will address patients who present with multifocal disease, giant colonic diverticulum, right-sided diverticulitis, and diverticulitis in the setting of immunosuppression and hopefully provide guidance for treatment in these special circumstances.Traditionally, management of complicated diverticular disease has involved open damage control operations with large definitive resections and colostomies. Studies are now showing that in a subset of patients who would typically have undergone an open Hartmann's procedure for Hinchey III/IV diverticulitis, a laparoscopic approach is equally safe, and has better outcomes. Similar patients may be good candidates for primary anastomosis to avoid the morbidity and subsequent reversal of a colostomy. While most operations for diverticulitis across the country are still performed open, there has been an incremental shift in practice toward minimally invasive approaches in the elective setting. The most recent data from large trials, most notably the SIGMA trial, found laparoscopic sigmoid colectomy is associated with fewer short-term and long-term complications, decreased pain, improvement in length of stay, and maintains better cost-effectiveness than open resections. Some studies even demonstrate that robotic sighown to have better outcomes, greater patient satisfaction, and fewer complications.Diverticulitis manifestations may cover a spectrum of mild local inflammation to diffuse feculent peritonitis. Up to 35% of patients presenting with diverticulitis will have purulent (Hinchey grade III) or feculent (Hinchey grade IV) contamination of the abdomen, with a high-associated morbidity and mortality. Surgical management may involve segmental resection with or without restoration of bowel continuity. However, emergency resection for diverticulitis can be associated with high mortality rates, as well as low stoma reversal rates at 1 year. https://www.selleckchem.com/products/sodium-dichloroacetate-dca.html Therefore, laparoscopic peritoneal lavage has been proposed for use in selected patients with purulent peritonitis. The topic of laparoscopic peritoneal lavage for the treatment of perforated diverticulitis in the literature has been controversial. Our review of the recent data show that laparoscopic lavage may be safe and feasible in select patients with similar rates of mortality and major morbidity. There is, however, a concern regarding an associated higher rate of postoperative abscess and early reintervention risk.The modern management of colonic diverticular disease involves grouping patients into uncomplicated or complicated diverticulitis, after which the correct treatment paradigm is instituted. Recent controversies suggest overlap in management strategies between these two groups. While most reports still support surgical intervention for the treatment of complicated diverticular disease, more data are forthcoming suggesting complicated diverticulitis does not merit surgical resection in all scenarios. Given the significant risk for complication in surgery for diverticulitis, careful attention should be paid to patient and procedure selection. Here, we define complicated diverticulitis, discuss options for surgical intervention, and explain strategies for avoiding operative pitfalls that result in early and late postoperative complications.Sigmoid diverticulitis represents a most common gastroenterological diagnosis in the western world. There has been a significant change in the management of recurrent uncomplicated diverticulitis in the last 10 to 15 years. The absolute number of previous episodes is not used as criteria to recommend surgery anymore. Young age is no longer considered to be an indication for more aggressive surgical treatment. It is accepted that subsequent episodes of diverticulitis are not significantly worse than the first episode. Laparoscopic surgery is now the standard of care for elective surgery for diverticulitis where expertise is available. There is a consensus that decision to perform sigmoid colectomy should be individualized, after careful risk benefit assessment.Uncomplicated diverticulitis is common, and its evaluation and treatment have evolved over time. Most patients present in a nontoxic manner with localized pain, leukocytosis, and reliable findings on computed tomography (CT). Healthy and stable patients are typically treated in the outpatient setting with very high rates of success. Recently, the necessity of antibiotic therapy has come into question, and several alternative agents have emerged, with the jury still out on their relative roles in diverticular disease. Currently, colonoscopy is still recommended after the resolution of an index episode of uncomplicated diverticulitis, and recurrence rates remain low. Several diet and lifestyle modifications have been shown to impact the rates of diverticulitis recurrence.Diverticular disease exists on a spectrum, ranging from asymptomatic diverticulosis to complicated diverticulitis. Incidence of diverticulitis in western nations has increased in recent years, although the factors that influence the progression from diverticulosis to diverticulitis are unknown. Geographic/environmental influences, lifestyle variables, and microbiota of the gastrointestinal tract are some of the factors implicated in diverticular disease.The use of general anesthesia for cesarean delivery has declined in the last decades due to the widespread utilization of neuraxial techniques and the understanding that neuraxial anesthesia can be provided even in urgent circumstances. In fact, the role of general anesthesia for cesarean delivery has been revisited, because despite recent devices facilitating endotracheal intubation and clinical algorithms, guiding anesthesiologists facing challenging scenarios, risks, and complications of general anesthesia at the time of delivery for both mother and neonate(s) remain significant. In this review, we will discuss clinical scenarios and risk factors associated with general anesthesia for cesarean delivery and address reasons why anesthesiologists should apply strategies to minimize its use.
Unnecessary general anesthesia for cesarean delivery is associated with maternal complications, including serious anesthesia-related complications, surgical site infection, and venous thromboembolic events. Racial and socioeconomic disparities and low-resource settings are major contributing factors in the use of general anesthesia for cesarean delivery, with both maternal and perinatal mortality increasing when general anesthesia is provided.